NCC201400_NOI Signed Certification_20200409

NCG01 Notice of Intent (N I) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOI_
Then, mail the original farm to the NC DEMLR Stormwater Program (with 100 check of paying by deck) a L:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61n Floor (Office 64DK)
1612 Mail Service Center
Raleigh, NC 27699-1512
DO NOT MAIL THIS FORM OR PAYMENT UNTIL YOUR (APPLICATION HAS BEEN
REVIEWED AND ACCEPTED AS COMPLETE
Per IVC General StatWte 14 3-15,68 (i), orny persoo who krnowingfy makes any false stotement, representation,
or certificotion in airy application, record, report, plar?, or other document feed or required to be maintained
under this Article or a rule impfementin g this Article ... shot) be guilty of a Class 2 misdemeonor which may
include a fine not to exceed tern thousand dollars (10,000),
Under enalty of law, I certify that (check all boxes to indicate ypur agreement).
[ I a m the person responsible for the construCtion activities of this project, for satisfying the
requirements of this {germ it, end for any civil or criminal penalties incurred due to violations of this
permit.
The infofimation submitted in this N01 is, to the best of my knowledge and belief, true, accurate, and
complete based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information,
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sedirrreot Control Plan.
If the approve[ Erosion and Sediment Control Plan is not compliant with Part II (5torrnater Pollution
Prevention Plan) of the NCG01D000 General Permit I wil I nonetheless ensure that all conditions of
rs/Part II of the permit are met on the project at all times.
1 hereby request coverage under tha NCG010000 General Permit and understand that coverage under
this hermit will constitute tl�e permit requirements for the discha(ges} and is enforceable in the
same manner as an individual permit.
name of Project: P N G Line 243 Retrofit Recei
Legally Responsible Organizational Entity: P a + "bAw't p7Xj Iv C,
Legal IV Responsible Person: aAA� A ed WRl ) Id G.ell
Titie of Legally Responsible Person; vfo�ec mokA
*Signature: Date. D 4 + U1 � J` -a
*Print Name and Title of Signet! if Authorized
Individual Differs from Permittee.
Phone Number
IMPORTANT NOTE: This form roust be signed by a responsible corporate officer thot owns or opergtes the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that t5
authorized in accordance with Part IV, Section B, item (6) of the NC601ODOO permit_
For more information on signatory requirements, see Part IV, Section 6, item (6) of the fUCGO) 0000 permie.